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F0583
F

Failure to Deliver Resident Mail on Saturdays

Conroe, Texas Survey Completed on 04-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents received their mail in a timely manner on Saturdays, as required. During a confidential group interview, all four alert and oriented residents interviewed reported that mail was not delivered on Saturdays. Multiple staff interviews revealed confusion and lack of clarity regarding who was responsible for delivering mail on weekends. The Administrator stated that the weekend receptionist and Managers on Duty (MODs) were responsible for mail delivery, but the Activities Director, HR staff, and Social Worker, all of whom served as MODs on alternating weekends, stated that delivering mail was not part of their assigned duties. Receptionists also reported that they did not deliver mail on weekends and that it was facility policy to hold Saturday mail for delivery on Monday. A review of the facility's policy on mail and electronic communication indicated that mail and packages should be delivered to residents within 72 hours of delivery, including Saturdays. Despite this policy, staff interviews confirmed that mail arriving on Saturdays was routinely held until Monday, resulting in residents not receiving their mail within the expected timeframe. The Administrator acknowledged that while there was no physical risk to residents, the failure to deliver mail on Saturdays could result in emotional distress.

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